Validation of END-of-life ScorING-system to identify the dying patient: a prospective analysis

BACKGROUND

The "END-of-Life ScorING-System" (ENDING-S) was previously developed to identify patients at high-risk of dying in the ICU and to facilitate a practical integration between palliative and intensive care. The aim of this study is to prospectively validate ENDING-S in a cohort of long-term critical care patients.

MATERIALS AND METHODS

Adult long-term ICU patients (with a length-of-stay> 4 days) were considered for this prospective multicenter observational study. ENDING-S and SOFA score were calculated daily and evaluated against the patient's ICU outcome. The predictive properties were evaluated through a receiver operating characteristic (ROC) analysis.

RESULTS

Two hundred twenty patients were enrolled for this study. Among these, 21.46% died during the ICU stay. ENDING-S correctly predicted the ICU outcome in 71.4% of patients. Sensitivity, specificity, positive and negative predictive values associated with the previously identified ENDING-S cut-off of 11.5 were 68.1, 72.3, 60 and 89.3%, respectively. ROC-AUC for outcome prediction was 0.79 for ENDING-S and 0.88 for SOFA in this cohort.

CONCLUSIONS

ENDING-S, while not as accurately as in the pilot study, demonstrated acceptable discrimination properties in identifying long-term ICU patients at very high-risk of dying. ENDING-S may be a useful tool aimed at facilitating a practical integration between palliative, end-of-life and intensive care.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02875912; First registration August 4, 2016.

In-line filtration reduced phlebitis associated with peripheral venous cannulation: Focus on cost-effectiveness and patients' perspectives

BACKGROUND

In a previous trial, in-line filtration significantly prevented postoperative phlebitis associated with short peripheral venous cannulation. This study aims to describe the cost-effectiveness of in-line filtration in reducing phlebitis and examine patients' perception of in-hospital vascular access management with and without in-line filtration.

METHODS

We analysed costs associated with in-line filtration: these data were prospectively recorded during the previous trial. Furthermore, we performed a follow-up for all the 268 patients enrolled in this trial. Among these, 213 patients responded and completed 6 months after hospital discharge questionnaires evaluating the perception of and satisfaction with the management of their vascular access.

RESULTS

In-line filtration group required 95.60€ more than the no-filtration group (a mean of € 0.71/patient). In terms of satisfaction with the perioperative management of their short peripheral venous cannulation, 110 (82%) and 103 (76.9%) patients, respectively, for in-line filtration and control group, completed this survey. Within in-line filtration group, 97.3% of patients were satisfied/strongly satisfied; if compared with previous experiences on short peripheral venous cannulation, 11% of them recognised in-line filtration as a relevant causative factor in determining their satisfaction. Among patients within the control group, 93.2% were satisfied/strongly satisfied, although up to 30% of them had experienced postoperative phlebitis. At the qualitative interview, they recognised no difference than previous experiences on short peripheral venous cannulation, and mentioned postoperative phlebitis as a common event that 'normally occurs' during a hospital stay.

CONCLUSION

In-line filtration is cost-effective in preventing postoperative phlebitis, and it seems to contribute to increasing patient satisfaction and reducing short peripheral venous cannulation-related discomfort.

The Valsalva manoeuvre versus tourniquet for venipuncture

BACKGROUND

During ultrasound-guided cannulation, venous filling is required for venipuncture. Tourniquet with an elastic tube at the axilla is the most common method to induce venous stasis for cannulation of the deep veins of the arm. Although effective, this method might be associated with short- and long-term complications. Valsalva manoeuvre has been used to produce venous filling in other extrathoracic veins. The aim of this observational study is to demonstrate the effect of Valsalva manoeuvre in respect of the elastic tourniquet on venous distention during echography-guided cannulation of the deep veins of the arm.

METHOD

Sixty-nine patients scheduled for cannulation of basilic or brachial vein were prospectively observed. Vein diameters were recorded at rest and after 10 s of Valsalva or tourniquet placement.

RESULTS

The mean difference between basilic vein diameters during tourniquet and Valsalva manoeuvre was 0.006 mm (95% confidence interval = -inf, 0.09) with a standard deviation of 0.5 mm (95% confidence interval = 0.5, 0.7; p > 0.01). The mean difference between brachial vein diameters during tourniquet and Valsalva manoeuvre was 0.04 mm (95% confidence interval = -0.23, 0.15) with a standard deviation of 0.8 mm (95% confidence interval = 0.7, 0.9; p > 0.01).

DISCUSSION

This increase in cross-sectional basilic and brachial vein diameters was not different to that obtained with the elastic tube tourniquet.

Infection of totally implantable venous access devices: A review of the literature

Totally implantable venous access devices, or ports, are essential in the therapeutic management of patients who require long-term intermittent intravenous therapy. Totally implantable venous access devices guarantee safe infusion of chemotherapy, blood transfusion, parenteral nutrition, as well as repeated blood samples. Minimizing the need for frequent vascular access, totally implantable venous access devices also improve the patient's quality of life. Nonetheless, totally implantable venous access devices are not free from complications. Among those, infection is the most relevant, affecting patients' morbidity and mortality-both in the hospital or outpatient setting-and increasing healthcare costs. Knowledge of pathogenesis and risk factors of totally implantable venous access device-related infections is crucial to prevent this condition by adopting proper insertion bundles and maintenance bundles based on the best available evidence. Early diagnosis and prompt treatment of infection are of paramount importance. As a totally implantable venous access device-related infection occurs, device removal or a conservative approach should be chosen in treating this complication. For both prevention and therapy, antimicrobial lock is a major matter of controversy and a promising field for future clinical studies. This article reviews current evidences in terms of epidemiology, pathogenesis and risk factors, diagnosis, prevention, and treatment of totally implantable venous access device-related infections.

An intensive monitoring campaign of PAHs for assessing the impact of a steel plant

This study provided a useful approach for assessing the impact of industrial sources on surrounding, especially in a sensitive industrial area as Taranto (South of Italy). Taranto is one of the most industrialized Italian towns, where several emission sources operate simultaneously in proximity to the urban settlement. An intensive monitoring campaign of PAHs was carried out from January 28th to July 30th, 2011, in seven sites located in residential settlement around the industrial area and in the city center. The collected data were integrated with the information about wind direction and speed by means bivariate polarplot in order to characterize and localize the industrial sources. High BaP concentrations were detected especially when Benzene to Toluene ratio (B/T ratio) values excedeed 1 and all receptor sites were downwind to the steel plant. Moreover, in order to discriminate among PAH sources and quantify their contributions, a source apportionment analysis of the collected data was provided by means Principal component Analysis (PCA) and Positive Matrix Factorization (PMF) methods. Finally, the processing of PMF5.0 output by bivariate polar plot, confirmed the impact of steel plant on both industrial sites downwind the steel plant and the city center. B[a]P apportionment was quite similar for industrial and urban sites: the traffic source contributed only 11% and 24% to B[a]P measured at two sites, respectively. Therefore, the proximity of Taranto downtown to industrial pole makes negligible all other source contributions to PAH concentrations.

[Source apportionment of benzo(a)pyrene in Taranto and carcinogenic risk estimate in general population]

INTRODUCTION

In 2009 the limit value of benzo(a)pyrene (BaP) in ambient air of 1.0 ng/m3 has been exceeded in the urban district of Taranto near to the industrial area, where a several large plants are located, including an integrated cycle steel plant.

OBJECTIVE

To identify emission sources and quantify relative contribution to the PAHs levels; to estimate health impact associated to PAHs exposure in general population.

METHODS

Multivariate receptor models have been used. Concentration of PAHs measured in 4 location in Taranto in 2008-2009 have been analyzed. 5 different models estimated profiles of unknown sources and identified significant chemical species. To compute the lung cancer risk the WHO unit risk estimate for BaP (8.7 x 10(5) ng/m3) has been adopted.

RESULTS

Models employed identify 3 to 4 emission sources. Estimated profiles have been compared with measured ones. Based on the average annual BaP level measured (1.3 ng/m3), 2 attributable cancer cases in the district Taranto population are estimated to result from a life-time exposure.

CONCLUSIONS

Among different emissive sources, the analysis identifies theoretical sources whose profiles, compared with observed data, allow to identify dominant contributions to PAHs pollution and to design corrective actions to reduce environmental and health impact.

[Laparoscopic or open appendectomy. Critical review of the literature and personal experience]

In the era of video-laparoscopic surgery there are a lot of surgeons that still continue to perform open appendectomy. This choice is the consequence of the good results of open appendectomy (clinical, cosmetic, hospital stays and hospital costs). Published trials on laparoscopic appendectomy don't show that it is superior to the open approach. The aim of this study is to critically review the literature on laparoscopic and traditional appendectomies and to report a clinical experience on 86 consecutive patients that underwent open appendectomy.

PATIENTS AND METHODS

From September 2000 to March 2001, in the Department of Emergency Surgery of Villa Scassi Hospital in Genoa, 86 patients underwent open appendectomy (32 men; mean age 29.8 years; range 15-54 years/54 women; mean age 22.4 years; range 13-80 years). All the patients underwent blood examinations, abdomino-pelvic ultrasonographys and the women gynecological evaluation. The Authors used, almost always, the Stropeni way of access (cutaneous Mac Burney and right para-rectal incision of the muscles). Discharge has been done as soon as possible. Removed appendices were submitted to histological examination and were classified as normal or pathologic according to the severity of the lesion. Review of articles has been done on Medline.

RESULTS

Suspected appendicitis have been confirmed by histological examination that documented 1 normal appendix, 7 chronic appendicitis, 45 acute catharralis, 22 acute suppurative and 11 gangrenous or perforated appendicitis. The specificity of open appendectomy has been 97.6% (100% for men). Post-operative complications were: 2 wound infections and 1 recurrence of an abscess (2.58%). Open appendectomy did carry an hospital bill of 2,500,000 IT liras (1,200 USA dollars) for non complicated appendicitis and 2,000 USA dollars for perforated appendicitis. The early discharge allowed us to spend 119 millions IT liras less in 7 months (99,600 USA dollars in a year).

DISCUSSION

The role of laparoscopic appendectomy isn't still established. After a critical review of the literature we can suggest that: 1) laparoscopic appendectomy increase operative time (63 vs 43 minutes: p < 0.0001); 2) laparoscopic approach can reduce the length of post-operative stay in hospital; 3) hospital bill is strongly reduced by open appendectomy (4,274 vs 7,923 USA dollars). On our experience the cost of the hospital for uncomplicated appendicitis is 2,500,000 IT liras (1,200 USA dollars). Otherwise it has been suggested that laparoscopic appendectomy has a better diagnostic accuracy respect to open appendectomy. Some Authors report a percentage of "negative" appendices of 16-50%. In Authors experience the percentage of "negative" appendices is 1.3% and so the diagnostic accuracy is 96% in women and 100% in men, probably because we systematically performed a preoperative abdomino-pelvic ultrasonography and, for the women, a gynecological evaluation. In conclusion, laparoscopic appendectomy should be done in case of suspected appendicitis in women. In the other cases, when there is a strong clinical suspect of appendicitis and, in particular, in case of suppurative appendicitis, the Authors recommend to perform an open appendectomy using the Stropeni approach. In case of perforated appendicitis with abdominal abscess they recommend to perform an open appendectomy using the right para-rectal approach or the median umbilical-pubis approach.

Oral iron chelating therapy. A single center interim report on deferiprone (L1) in thalassemia

BACKGROUND AND OBJECTIVE

Deferiprone (L1) is a largely studied oral chelator in clinical setting, however, no definite conclusions concerning efficacy and toxicity still could be drawn. In an ongoing prospective trial with L1, we evaluated the efficacy and tolerance-toxicity in patients with thalassemia major previously treated by desferrioxamine (DFO); the specific aim of the study is to demonstrate that L1 could be an alternative to DFO in some patients with an acceptable toxicity.

DESIGN AND METHODS

Sixty-nine patients over 13 years of age with poor compliance to DFO were considered for the study. The design included a liver biopsy before starting L1 in all patients in order to define liver siderosis either by histologic grading or by hepatic iron concentration (HIC); only patients with a minimum HIC of 4 mg/g dry weight entered the study. A repetition of the liver biopsy after one year of L1 was planned; further evaluations included serum ferritin, plasma iron, transferrin TIBC and iron urine excretion. L1 was given at 70 mg/kg/day in three divided doses. Toxicity was monitored either clinically or by controlling liver, kidney and marrow function by specific tests. Concerning clinical characteristics 52 patients showed hypogonadism (78%), 39 growth retardation (58%), 6 diabetes (9%), 4 cardiomyopathy (6%), 9 hypothyroidism (12%); 45 patients had chronic liver damage (65%).

RESULTS

We focus this report on data collected in a group of 29 patients with a minimum follow-up of one year (14-33 months). The mean ferritin value was 3748 ng/mL (range: 200-10,000) and 2550 ng/mL (range: 80-14,500), before and while on L1 therapy, respectively (p = 0.001); the mean sideruria changed from 17.25 mg/dL (range: 5.4-50) to 20.98 mg/dL (range: 10-40), on DFO and L1, respectively (p = 0.078); the ratio between plasma iron (sideremia) and transferrin TIBC changed from 0.96 with DFO to 0.86 with L1 (0.014). A correlation with grade of liver siderosis and serum ferritin (p = 0.069) and iron urine excretion (p = 0.008) was recorded. The judgement of efficacy showed that L1 was effective (EF) in 9 patients, no assessable (UN) in 11 patients, not effective (NE) in 2 patients and with no advantages with respect to DFO in 7 patients. Liver biopsy was repeated in 20 patients showing a reduction of grade of liver siderosis and iron content in 7 patients. Clinical toxic effects of L1 were gastric intolerance (one patient), joint pain (three patients) and mild and temporary neutropenia (one patient).

INTERPRETATION AND CONCLUSIONS

This preliminary experience shows that L1 is effective in several patients with thalassemia with poor compliance to DFO and to improve iron burden and iron excretion with generally minor side effects. L1 could be an alternative to DFO in some patients, however the recognition of neutropenia warrants a careful evaluation of patients and efforts finalized to early recognition of those to be addressed with this new and still experimental therapy.

Iron overload in thalassemia: comparative analysis of magnetic resonance imaging, serum ferritin and iron content of the liver

BACKGROUND

Iron overload in patients with thalassemia is a common feature which requires continuous chelation therapy and monitoring. Serum ferritin determination is widely accepted as a simple method for following iron load in patients with primary hemochromatosis; however, several reports on thalassemic patients emphasize that ferritinemia is not accurate and that other methods such as direct measurement of iron in the liver (HIC) and magnetic resonance imaging (MRI) are more precise.

MATERIALS AND METHODS

In order to contribute to the general understanding of iron load in thalassemia we used liver MRI to study 33 thalassemic patients, most of whom were also evaluated for iron content by liver biopsy. The data were then compared with serum ferritin levels.

RESULTS

Ferritin levels ranged between 276 and 8031 ng/mL, and liver iron content ranged from 1.6 to 31.0 mg/g dry weight; grade III or IV liver siderosis was recorded in 23/33 patients, just as 23/33 patients were found to have severe or very severe siderosis at MRI. Significant correlations with ferritin levels were recorded between grade IV and grades III, II and I (p < 0.01, p = 0.02, and p = 0.03, respectively). Ferritinemia also showed significant linearity with liver iron content (r = 0.603, p = 0.001). No significant differences of levels were recorded, however, between patients found to have severe and those with mild iron load at MRI (p = 0.073).

CONCLUSIONS

Our study shows that serum ferritin levels exhibit a tendency to be significantly correlated with the true status of hemochromatosis in thalassemic patients; however, the discrepancies recorded in several patients and the scarce or total lack of correlation with MRI suggest exploring other approaches to this problem in order to make proper decisions about therapy.

[Tracheobronchial reconstructive surgery: protection of the tracheal anastomosis. Our experience]

In line with data reported in the literature, the authors consider that the careful protection of the tracheal suture with abundant vital tissue is of fundamental importance in the prevention of complications in tracheal resective-reconstructive surgery. This procedure in fact reduces the risk of necrosis and subsequent fistulization of tracheal tissue and prevents decubitus of the suture on the innominate arterial wall, avoiding possible ulceration with fistulization and tracheal hemorrhage.

[Thoracic surgery with a video endoscopic technic. The authors' own experience]

The authors illustrate the current possibilities and limitations of a leading-edge technique, thoracoscopic surgery, made possible by the enormous technical progress which has led to the creation of specific visual and surgical instruments. On the strength of their personal experience, they list the different diseases which may be treated using video thoracoscopic surgery.

[Use of minitracheotomy in high-risk pulmonary resection surgery. Results of a comparative study]

Twenty patients undergoing lung resections were randomized into two groups: group 1 (n = 10) received mini-tracheotomy postoperatively and group 2 (n = 10) were control patients. The two groups were similarly matched in pulmonary functions (FEV1 < 1.8 1), performance status and surgical procedures (major pulmonary resections). All patients were monitored by serial chest X-ray examinations, arterial blood gases, clinical assessment and response to chest physiotherapy. Postoperative pulmonary complications of atelectasis/bronchopneumonia developed in 1 patient in group A and 4 patients in group B. Two patients of this last group required mini-tracheotomy to treat the pneumonia. The mean overall duration of mini-tracheotomy was 6.3 days. Five patients presented minor temporary symptoms related to mini-tracheotomy, including voice changes, discomfort and stridor. No long term morbidity was observed. We concluded that the use of mini-tracheotomy is safe and effective in decreasing postoperative respiratory morbidity in high risk patients.

[The surgical therapy of pulmonary aspergilloma. Our experience]

Between 1971 and 1986 11 patients suffering from pulmonary aspergilloma were seen in the thoracic surgery service at Genova-Sampierdarena Hospital. Nine patients underwent thoracotomy. Lobectomy was the most frequent operation. Complications occurred in 3 patients (33%). There were no recurrent symptoms in any of them over a mean follow-up of 4 years. The remaining two patients were treated by instillation of antifungal agents into the aspergilloma cavity. There was no systemic toxicity and in one patient the mycetoma resolved. The authors conclude that pulmonary resection can provide effective long-term treatment, while intracavity infusion of antifungal agent can be a successful nonoperative method in critically ill patients.

[Surgery in the treatment of pulmonary carcinoma with mediastinal lymph node metastasis (N2)]

This study is based on the analysis of the survival data in patients with N2 disease reported by Martini, Pearson, Shields et al. Many factors appear to influence survival of this group of patients. We made a retrospective analysis of a series of 91 patients with N2 disease between January 1980 and March 1985. Sixty-nine patients (71.5%) presented clinically N2 disease; 44 patients (63.7%) were treated with complete resection and postoperative irradiation, the actuarial five year survival was 11%. Twenty-two patients (24.2%) were discovered to have N2 disease at thoracotomy. Twenty-one patients underwent resection and the actuarial five year survival was 29%. We conclude that surgery can be effective in a highly selective group of patients.

Chest wall involvement by lung cancer: computed tomographic detection and results of operation

The aim of this prospective study was to evaluate: (1) the role of computed tomographic scanning in predicting chest wall invasion by peripheral lung cancer and (2) the results of operation according to the depth of chest wall involvement and other potential indicators of long-term survival. One hundred twelve patients with non-small cell lung cancer adjacent to the pleural surface who underwent computed tomographic scanning and subsequent thoracotomy were entered into this study. Tumor invasion was confined to the visceral pleura in 53 patients, to the parietal pleura in 18 patients, and to intercostal muscles in 25 patients; invasion extended beyond this layer in 16 patients. The computed tomographic criteria for chest wall invasion were (1) obliteration of the extrapleural fat plane, (2) the length of the tumor-pleura contact, (3) the ratio between the tumor-pleura contact and the tumor diameter, (4) the angle of the tumor with the pleura, (5) a mass involving the chest wall, and (6) rib destruction. The computed tomographic criteria 1 and 3 were significantly related to pathologic findings. Sensitivity was 85% for criterion 1 and 83% for criterion 3, specificity being 87% and 80%, respectively. Long-term survival of patients with T3 disease critically depended on the lymph node state and completeness of resection. The adenocarcinoma cell type and the T4 category were unfavorable prognostic factors. The depth of chest wall invasion did not affect survival, except for extensive rib and soft tissue infiltration. En bloc resection yielded better results than discontinuous resection.

[Mediastinal goiters. A clinical case series]

The paper described the treatment of a series of 47 mediastinal goitres. The importance of a thorough preoperative assessment of the lesion and of careful planning of the operative technique are underlined. Cervical collar incision provided adequate exposure in most patients. The Authors conclude that surgical treatment should be recommended in all cases.

[Automatic sutures in bronchopulmonary surgery]

Efficacy of automatic staplers in broncho-pulmonary surgery was evaluated in a series of 316 consecutive patients. The results confirm that utilization of staplers has drastically reduced the incidence of post-resection bronchial fistulae; moreover on parenchymal tissue such instruments guarantee excellent haemostasis and air tightness. On the contrary, indications for their use on pulmonary vessels seem to be very limited.

[Remote results in 214 cases of surgically treated breast carcinoma]

The Authors report the remote results of 214 cases of breast cancer, operated in the period August 1963-December 1974, after subdividing the cases they had the opportunity to observe on the basis of the stage of the disease, the surgical treatment and the eventual post-mastectomy precautionary therapy.

[A rare case of glomus tumor of the fingers]

The Authors report an observation of glomic tumour of fingers in a man aged 68. After a reviewing of the literature thereabout, they dwell upon the rareness of this disease and upon its main clinical manifestations. The angiographic study completed is remarkable. The Authors, as a conclusion, confirm the need of a surgical treatment.

[A case of gastric neurinoma: a rare cause of digestive hemorrhage]

The Authors, after shortly explaining the main anatomo-pathological and clinical features of gastric neurinoma, describe a case they had the opportunity to observe, and appearing, in full welfare, exclusively through the symptoms of a serious gastrointestinal hemorrhage.

[Our experience in the surgical therapy of myasthenia gravis]

The Authors, in the present work, describe the clinical and diagnostic features of Myasthenia Gravis, and, on the basis of their casuistry and the international scientific literature, remark the necessity of the surgical operation as the basic therapeutic chance for the resolution and improvement of the disease.